Evaluating disparities in code status designation among patients admitted with COVID-19 at a quaternary care center early in the pandemic

The COVID-19 pandemic has highlighted disparities in outcomes by social determinants to health. It is unclear how much end-of-life discussions and a patient's decision about code status ("do not resuscitate," do not resuscitate, or "comfort measures only," [CMO] orders) might contribute to in hospital disparities in care, especially given know racial inequities in end-of-life care. Here, we looked at factors associated with code status orders at the end of hospitalization for patients with COVID-19. We conducted a retrospective chart review of all patients who presented to the Emergency Department of a large quaternary hospital between 8 March and 3 June 2020. We used logistic regression modeling to quantify the degree to which social determinants of health, including race, ethnicity, area deprivation index (ADI), English as a primary language, homelessness, and illicit substance use might impact the likelihood of a particular code status at the end-of a patient's hospitalization, while controlling for disease severity. Among social determinants to health, only white race (odds ratio [OR] 2.0; P = .03) and higher ADI (OR 1.2; P = .03) were associated with having a do not resuscitate or a CMO order. Additionally, we found that patients with white race (OR 2.9; P = .02) were more likely to carry a CMO order. Patient race and ADI were associated with different code status orders at the end of hospitalization. Differences in code status might have contributed to disparities in COVID-19 outcomes early in the pandemic, though further investigations are warranted.